Life Care Center of Nashoba Valley

In the surveyor’s words

From the most serious findings on record at Life Care Center of Nashoba Valley, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF584May 26, 2022

  Based on observations and interviews, the facility failed to maintain a homelike environment on 3 out of 3 resident units. Findings include: 1. During environmental rounds on 5/26/22 at 7:45 A.M., the following was observed on the Memory Care Unit: *In room 4, there was plaster exposed on the wall behind the B bed. *In room 5, there were significant black marks on the wall across from the A bed and there was plaster exposed on the wall in the bathroom. *In room 6, there were gouges in the wall behind B bed with plaster exposed and the baseboard trim was not painted. *In room 7, the bottom of the bathroom door was significantly scuffed with black marks, there was a missing ceiling tile in the bathroom and the commode over the toilet had significant rust. […]

• No harm, potential for more than minimal, patternF609May 26, 2022

  Based on record review, interview, and facility policy, the facility failed to report bruises and skin tears of unknown origins for three Residents (#63, #64, and #68) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 5/15/20, indicated the following: - All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. 1. Resident #63 was admitted to the facility in October 2009 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF610May 26, 2022

  Based on record review, and interview, the facility failed to investigate a bruise and/or skin tear of unknown origin for three Residents (#63, #64, and #68) out of a sample of (20) residents. Findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 5/15/20, indicated the following: - When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. 1. Resident #63 was admitted to the facility in October 2009 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF759May 26, 2022

  Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5%. The surveyor observed 3 of 4 licensed nurses make errors while administering medications on 2 of 3 resident care units. Four errors in 26 opportunities were observed resulting in a medication error rate of 15.38%. Findings include: Review of the facility policy titled Administration of Medications and dated as revised 4/29/22, indicated all medications are to be administered appropriately per physicians' order and standards of practice. 1. […]

• No harm, potential for more than minimal, patternF886Sep 22, 2021

  Based on interview and record review, the facility failed to maintain compliance with COVID-19 testing of unvaccinated staff. Findings include: Review of the facility's COVID-19 (SARS-CoV-2) Testing - Massachusetts Addendum, revised 8/19/21 indicated that if a staff member is not fully vaccinated, meaning at least two weeks after their second dose in a two-dose series, such as the Pfizer or Moderna vaccines, or two weeks after a single-dose vaccine, such as [NAME] & [NAME]'s [NAME] vaccine, the facility must perform BinaxNOW testing on the individual prior to beginning to work a shift. Review of the facility's unvaccinated staff list, revised 9/8/21, indicated that Nurse #1 was not fully vaccinated. […]